http://dx.doi.org/10.1590/1981-22562018021.

180119

Artigos Originais / Original Articles

Validation of a questionnaire for the evaluation of informal social
support for the elderly: section 1

647
Marcello Barbosa Otoni Gonçalves Guedes1
Kenio Costa Lima¹
André Luiz Lima¹
Thais Sousa Rodrigues Guedes²

Abstract
Objectives: to construct and carry out content (CV) and response process (RPV) validation
for a questionnaire to assess informal social support for the elderly. Method: a descriptive,
observational, quantitative study was performed between January and December 2016
in the city of Natal (Rio Grande do Norte) and other locations in Brazil. The inclusion
criteria were: proven experience in the area of social support (for experts) or 60 years of
age or older and with preserved cognitive status (for the elderly). The CV stage evaluated Keywoods: Social Support.
the relevance of the items according to the general Content Validity Index (CVI) and Health of the Elderly.
per item as well as the assembly of the panel based on the observations of the experts. Surveys and Questionnaires.
In the RPV stage, the understanding of the items by the target audience was evaluated. Validation Studies.
Results: the CV stage included a total of 40 interviewees. The overall CVI was 0.88 and
only one item had a CVI considered poor. In the RPV stage 41 people were interviewed.
Conclusion: the questionnaire exhibited good relevance for the proposed items and the
observations of the interviewees allowed an approximation of the language used in the
instrument to the language of the elderly.

1
Universidade Federal do Rio Grande do Norte, Departamento de Odontologia, Programa de Pós-graduação
em Saúde Coletiva. Lagoa Nova, Natal, Brasil.
² Universidade Federal do Rio Grande do Norte, Programa de Pós-graduação em Ciências da Saúde. Lagoa
Nova, Natal, Brasil.

Funding: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - (CAPES) – Brazil - Code

001. Scholarship for doctorate.

Correspondence
Marcello Barbosa Otoni Gonçalves Guedes
marcelloguedes21@hotmail.com
 Rev. Bras. Geriatr. Gerontol., Rio de Janeiro, 2018; 21(6): 647-656
INTRODUCTION
Social relations, when inadequate, constitute an
obvious health risk, comparable to others proven to
be harmful, such as smoking, high blood pressure,
obesity and sedentary lifestyle, and may have clinical
implications for people's health1. Social support (SS)
648 seems to have a broad impact in many aspects of
people's lives, especially in populations that are
vulnerable in social, psychological and health terms,
as is the case of the elderly2.
SS composes the social and individual coping
resources in which people base their responses
to everyday needs and stressful situations3. An
individual’s assessment of their SS as successful
has been related to several positive outcomes in
physical and mental health, influencing how stressful
situations are perceived, emotional and psychological
well-being and even longevity3,4,5.
The differentiation of social support relationships
according to their content, process and development
can directly impact the adaptation of individuals to
their social environment. From this perspective,
SS must be evaluated by distinguishing its types in
accordance with the relationships that give rise to
it6. In scientific literature it is common to observe
a differentiation between Formal Social Support
(FSS), which includes state services, social security,
and diverse organizations, such as church groups and
health professionals, among others, and Informal
Social Support (ISS), which includes the network
of relatives, friends and neighbors, for example7,8.
Isolating and breaking links within the ISS network
could increase the vulnerability of individuals to
illness and become a barrier to achieving active
aging. ISS, therefore, is the main source of support
for many elderly people and, on many occasions,
the only one9,10.
In light of the above and other assumptions
regarding scientific evidence in the evaluation
process11, the importance of using instruments
constructed and validated for the analysis of ISS is
clear, due to the scarcity of resources in literature
for the evaluation of this specific construct3. Most
such instruments deal with Formal Social Support
or do not separate the constructs from one another
among the elderly population12,13,14.
Within the logic of the systematization of
the evaluation process, it is important that such
instruments follow the methodological rigor of
the stages of the validation process15,16. The careful
evaluation of ISS can become excessively complex,
abstract and subjective, if validated evaluation
tools are not used in the research process. There
are multiple observation variables, which can cause
difficulty for exclusively subjective observations.
Validity refers to the ability of an instrument to
accurately measure the phenomenon being studied,
or in other words, to what extent it can actually
assess its objective17. For the construction and
validation of a questionnaire, the steps of "content-
based validity" and "response process validity " are
required, which can be carried out by qualitative and
quantitative procedures, according to the proposed
methodology15,17-19. When validation is considered as
a process, the publication of steps already carried out
for a certain instrument foments academic discussion
and consequently, the creation of new researches that
corroborate its validity. Other steps to improve the
instrument, such as Exploratory and Confirmatory
Factor analysis, accuracy analysis and cross-cultural
adaptations, are necessary and will be dealt with in
later sections, as some have already been performed
by the research group responsible.
Content-based validity assesses the degree to
which each element of an instrument of measurement
is relevant and representative of a specific construct
with a particular purpose for evaluation, and is
usually developed through a comprehensive literature
review, consulting experts by interviews, group
discussion (focus groups) or panel building, followed
by assessment by judges18,20.
Response process validity encompasses the
analysis of interviews with lay people potentially
related to the study population and the subsequent
evaluation of judges. This step ensures the correction
of sentences and an approximation of the language
used in the instrument to the language frequently
used by the target population, thus discarding
terms that were not clear for this audience15,17,20.
Unfortunately, most authors do not describe these
steps in detail. Therefore, the purpose of this section
is to analyze the content and response process validity
of a questionnaire that seeks to evaluate Informal
Social Support for the Elderly.

METHOD
Research Characteristics
A descriptive, observational, quantitative type
research was carried out. The present study took
place between January and October 2016, as part
of the project "Construction and Validation of a
Social Support Scale for the Elderly". This research
project comprised two stages of the process of the
construction and validation of the questionnaire:
content and response process validity15,18.
Data Collection
The first stage referred to content-based validity,
where the judges selected the items after a thorough
review of the literature for the preparation of the
first version of the instrument16. Subsequently, the
relevance of the items was judged by experts. The
initial construction of the questions concerning
the first model of the questionnaire was therefore
carried out by two academic judges from the area
of Social Support, with the choice of each item
always consensual, following a review of literature.
The questionnaire was then issued to specialists via
the internet, using the following inclusion criteria:
authors of scientific articles in the area, professors of
Psychology and Social Services courses (those who
train professionals working close to the evaluation and
management of social support among the elderly) and
professionals who worked directly with the theme.
The sample at this stage was selected for
convenience and included 40 experts. Contact was
made following the creation of an e-mail database
of the authors responsible for the publication of
articles available in the virtual computer network and
contact with professors available on the websites of
their respective institutions of higher education or
the personal invitation of professionals in the area.
The invitation was simultaneously sent to all experts
through the SurveyMonkey® research tool. The letter
of invitation contained the following words: "Social
support is an important determinant for the health of
a range of elderly people. This study aims to construct
and validate a questionnaire for the evaluation of
Informal Social Support for the elderly. This is the
initial stage of the research, in which researchers and
experts participate in the theme of Informal Social
Validity of the Informal Social Support Questionnaire
Support, to evaluate the relevance of the proposed
items and possible changes or the addition of new
items. Your participation is voluntary and will be
given through the answers made in this questionnaire.
If you feel comfortable answering the questions, you
will be making a significant contribution to our
research." All participants accepted the free and
informed consent form. 649
The second stage of response process validity was
also carried out with a convenience sample, totaling 41
people (target population), in face-to-face interviews,
selected in a long-term institution, an association for
the elderly and a public health system clinic, all located
in the city of Natal, Rio Grande do Norte (RN).
The inclusion criteria were: 60 years old or older
and with cognitive ability maintained (no clinical
diagnosis of cognitive deficit). All participants
signed the informed consent form. In addition to
ISS questions, respondents were asked about their
age, gender, schooling, and income. At this stage,
participants were asked whether they understood
each item or not, were asked to repeat the questions,
and encouraged to suggest changes. In addition, the
non-verbal reactions of respondents were observed
during the question process (e.g. facial expressions
of doubt or discomfort) along with long response
times15,18,21. The maintenance, alteration or exclusion
of the items occurred by the consensus decision of
the judges after the construction of a panel with
the information provided by the interviewees 17,22.
Data Analysis
The questionnaire addressed to the experts asked
for answers regarding level of schooling, as well as
multiple choice and open questions relating to the
proposed items with the following words: "1- Classify
each question below according to degree of relevance
for the evaluation of Social Support for the elderly"
(responses in this question followed the Likert Scale
structure: 1- Irrelevant, 2- Not Very Relevant, 3-
Relevant, 4- Very Relevant, 5- Extremely Relevant);
2- "If you would like to suggest the inclusion of an
item, do so in the text box below"; "3- If you would
like to suggest changes to an item, please state the
corresponding number and how you would like it
changed in the text box below”17.
 Rev. Bras. Geriatr. Gerontol., Rio de Janeiro, 2018; 21(6): 647-656

In order to determine the degree of relevance of RESULTS

the items and the overall relevance of the instrument,
the Content Validity Index (CVI) was used to
measure the degree of relevance of each item, based
on the answers of the judges (responses 3, 4 or 5 were
considered suitable), where: CVI by item = number
of suitable judgments (answers 3+4+5)/total number
650 of judgments. Items with a CVI greater than or equal
to 0.8 were maintained23. The overall CVI indicates
the degree of relevance of the mean of the entire
instrument, where Overall CVI = Overall Mean of
all Suitable Responses/total number of judgments.
The maintenance, alteration or exclusion of the items
was based on the consensus decision of the judges
after the construction of a panel with the information
provided by the interviewees and the analysis of the
CVI of the items20,22,23.
In terms of descriptive analysis, in the content-
based validity stage with experts, 90% of the
interviewees were doctors, 7.5% were masters and
2.5% were specialists. The response process validity
phase involving the elderly included a total of 41
interviewees, 17 (41.5%) of whom were males, 24
(58.5%) of whom were women, and the mean age
of whom was 70.87 (±8.01). The majority (39.0%)
had completed primary education, followed by
secondary education (26.8%), and higher education
(22.0%), those with no education (7.3%) and those
with a post-graduate qualification (4.9%). The
average income was: 2439.02 reais (± 2792.86).
Table 1 shows the results of the overall CVI and
per item.

Chart 1 provides suggestions for changes and

Ethical Aspects
This project was approved by the Ethics Research
Committee of the Hospital Universitário Onofre
Lopes, under approval number 1.644.533 and CAAE
54608616.8.0000.5292. The present study complied
with Resolutions nº 196/96 and nº 466/2012, of the
National Health Council (CNS).
the additions of new items made by experts. Chart
2 shows a comparison of before and after changes
in the items after such suggestions. Chart 3 shows
a comparison of before and after changes in the
items after the suggestions of the elderly. Chart 4
presents the proposal of the questionnaire after
validity steps based on the content and process
of responses.

Table 1. First version of items proposed by judges following a review of literature and the Content Validity Index
(CVI) by item and overall, according to the judgement of relevance by experts. Natal, Rio Grande do Norte, 2018.
Item Content Value Index by item
1. Can sir/madam rely on many people that are close to him/her? 0.92
2. Does sir/madam live with many people? 0.82
3. Does sir/madam have close friends? 0.90
4. Does sir/madam have a close relative that lives nearby? 0.90
5. Does sir/madam have a friend that lives nearby? 0.92
6. Does sir/madam have a neighbor present? 0.88
7. Does sir/madam often pay visits other people? 0.88
8. Does sir/madam often have visitors? 0.90
9. Does sir/madam have anyone to talk to? 0.92
10. Does sir/madam have someone to help with the housework? 0.92
11. Does sir/madam have someone to help them leave the house when they need it? 0.92
12. Does sir/madam have someone to help when they are bedridden or sick? 0.95
13. Does sir/madam have someone to help when they have financial difficulties? 0.95
14. Does sir/madam take part in discussions about family decisions? 0.90
15. Does sir/madam take part in discussions about decisions among friends? 0.82
to be continued
 Validity of the Informal Social Support Questionnaire

Continuation of Table 1
Item Content Value Index by item
16. Does sir/madam take part in discussions about community decisions? 0.82
17. Does sir/madam listen to the problems of others when asked? 0.90
18. Does sir/madam comfort others when asked? 0.88
19. Does sir/madam share their leisure time with someone? 0.95
20.Is social contact with others enduring? 0.88
21.Was the help that sir received from others in the last 30 days adequate? 0.82 651
22. Did sir receive adequate help from other people when young? 0.65*
CVI – Overall 0.88
*Value below reference value of 0.8 .
23

Chart 1. Observations for amendments and suggestions for the inclusion of items of specialists accepted by
judges. Natal, Rio Grande do Norte, 2018.

Observations of specialists accepted

Restriction to Informal Social Support in the header
Use of the singular to facilitate understanding
Reduction of the number of words in some sentences
Use "you" instead of "sir/madam"
Suggestions for the inclusion of items by specialists accepted
When you are sad or miss someone do you have anyone to talk to?
Do you have close relatives who help you look after yourself when you need it?

Chart 2. Items with and without alterations, following specific suggestions of specialists accepted by judges.
Natal, Rio Grande do Norte, 2018.
Unaltered item
Did sir/madam receive adequate help from other people
when young?
Does sir/madam take part in discussions about family
decisions?
Does sir/madam participate in discussions about
decisions among friends?
Does sir/madam listen to the problems of others when
asked?
Does sir/madam often have visitors?
Does sir/madam have a friend that lives nearby?
Was the help that sir received from others in the last 30
days adequate?
Does sir/madam have a neighbor present?
Does sir/madam have a relative that lives nearby?
Is social contact with other people enduring?
Reformulated Item
When you were young, did you receive adequate help
from other people?
Do you take part in family decisions?
Do you take part in decisions among friends?
Do you listen to the problems of others when asked?
Do you often have visitors?
Do you have a friend you see often?
Was the help you received in the last 30 days satisfactory?
Do you have a neighbours you can rely on when
required?
Do you have a relative you can rely on and who lives
nearby?
Is your social contact with other people enduring?
 Rev. Bras. Geriatr. Gerontol., Rio de Janeiro, 2018; 21(6): 647-656

Chart 3. Items with and without alterations following suggestions of target audience accepted by judges. Natal,
Rio Grande do Norte, 2018.
Unaltered item Reformulated Item
Do you have a relative that you can rely on and who lives Do you have a family member that you can rely on and
nearby? who lives nearby?
Do you often pay visits? Do you often visit other people?
Do you have someone who can help you leave the house Do you have someone who can help you leave the house
652 when you need it? in case you need it?
Do you have someone to help when you’re bedridden or Do you have someone to help in case you’re bedridden or
sick? sick?
Do you have someone to help when you have financial Do you have someone to help in case you have financial
difficulties? difficulties?
Do you take part in family decisions? Have you taken part in a family decision?
Do you listen to the problems of others when asked? Do you help others when asked?
Do you comfort others when asked? Do you console others when they’re sad?
Is your social contact with others enduring? Is your social contact with others permanent?
Was the help that you had or would have had in the last Was the help that you had or would have had in the last
30 days satisfactory? 30 days satisfactory, or would it have been?

Chart 4. Informal Social Support Questionnaire for the Elderly following content and response process evaluation
stages. Natal, Rio Grande do Norte, 2018.
Informal Social Support is all emotional, financial, material or daily support for activities of daily living, received by a
network of people (relatives, friends, neighbors, among others).
INDICATE THE OPTION THAT YOU BELIEVE TO BE MOST SUITABLE FOR EACH ITEM REFERRING
TO INFORMAL SOCIAL SUPPORT AMONG THE ELDERLY
Item/Response alternatives YES NO
1.Can you rely on people close to you?
2. Do you live with many people?
3. Do you have a friend you see often?
4. Do you have a family member you can rely on and who lives nearby?
5. Do you have a friend that lives nearby?
6. Do you have a neighbor who you can rely on in case you need it?
7. Do you often visit other people?
8. Do you often have visitors?
9. Do you have someone you can talk to?
10. Do you have someone to help with the housework?
11. Do you have someone to help you leave the house in case you need to?
12. Do you have someone to help you in case you’re bedridden or sick?
13. Do you have someone to help you in case of financial difficulty?
14. Have you taken part in a family decision?
15. Do you take part in decisions among friends?
16. Have you taken part in a community decision?
17. Do you help other people when asked?
18. Do you console other people when they’re sad?
19. Do you share your leisure time with anyone?
20. Is your social contact with other people permanent?

to be continued

Continuation of Chart 4
Item/Response alternatives
21. Was the help that you had or would have had in the last 30 days satisfactory,
or would it have been?
22. Have you received adequate help from other people throughout your life?
23. When you are sad or miss someone do you have anyone to talk to?
24. Do you have a family member who helps you look after yourself in case you
need it?
DISCUSSION
Some points for reflection concerning the
construction and validation of instruments should
be highlighted. It is important to understand this
process as a collection of resources and procedures
that are organized as a process and not as a finished
product. The stages of the validation process should
complement each other and the level of evidence
obtained by the instrument to measure a given
construct or phenomenon should be constantly
evolving15,21,24,25 .
In terms of descriptive analysis, a high degree
of education and training was observed among the
expert participants regarding the content-based
validity sample, which could reduce response errors
caused by a failure to understand the questions or
the purpose of the study. All levels of education were
represented among the respondents of the response
process validity stage, from "uneducated" to formal
postgraduate education, with a quantitative balance
between men and women. In addition, data collection
was performed in both a long-term institution and in
public places. These aspects reinforce the applicability
of the questionnaire whether in an institutionalized
or non-institutionalized population.
Content-based validity was measured using a
panel of experts17. This tool was integrated into the
research as part of a preliminary phase, contributing
to the establishing of the bases for research. This
phase was important to support the eradication of bias
and false evidence about the construct studied17,20,26 .
The general observations made by the experts
regarding the instrument resulted in a reduction in
the length of sentences, making them more objective,
which could reduce the final application time of
Validity of the Informal Social Support Questionnaire
YES NO
653
the questionnaire18. The language of the sentences
was also improved, which could strengthen the
link between the respondent and the process of
applying the instrument and thus increase adherence,
leading to all the questions being answered, and
also facilitate the understanding of the interviewee,
reducing response bias27. It was suggested that the
questionnaire was restricted to the object of study
of "Informal Social Support", which was not clear in
the first version and was also accepted by the judges.
The experts also suggested the inclusion of some
items. Accepted suggestions covered important
questions that include variables that directly influence
perceived informal social support and are presented
as important dimensions for the evaluation of the
construct studied. These are: "emotional support
and social participation" and instrumental support
or availability28-30.
Regarding the CVI, the overall index was
satisfactory, demonstrating the general relevance
of the items initially included in the instrument 23.
Item twenty-two, "Did you receive adequate help
from other people when you were young?", was the
only question with an unsatisfactory performance
according to the item based CVI 23 and was
restructured in a way that facilitated understanding
and gave the idea of perceived informal social support
throughout life. It was therefore restructured as
follows: "Have you received adequate help from
other people throughout your life?”.
On some occasions, experts can be an authority
on the subject studied, but when suggesting issues
pertinent to the topic, may do so in a language of
debatable comprehension for the target audience. The
response process validity stage is therefore important
to bring the language used in the instrument closer
 Rev. Bras. Geriatr. Gerontol., Rio de Janeiro, 2018; 21(6): 647-656
to the target audience's usual language, making it
potentially more comprehensible15,21.
The collection of direct and indirect indicators,
such as the answers about the understanding of each
question and the reaction of the interviewees to each
question, was important in this stage of interviews
654 with the elderly 21. The documentation of the
reactions and perceptions about the understanding
of the questions by the target population, with
the subsequent creation of the panel for this
population, allowed the specificities of this group
to be captured, which was only possible through
face-to-face interviews.
The choice of the format of answers for the elderly,
in terms of the understanding or not of each question,
was dichotomous instead of using, for example, a
Likert type scale. This format of responses could
facilitate the interviewee's understanding and reduce
the amount of random responses18. Regarding the
analysis of the responses of the target population, in
terms of the understanding of each item, the analysis
was specific by item, with the aim of maximizing
the understanding of the sentence according to the
objective of evaluation proposed by the question
and reducing the possibility of "does not apply”
type answers”22 . The specificities of the studied
population were therefore taken into account in
the analysis of the acceptance or rejection of the
proposed changes.
The questions used a language close to that most
commonly spoken by the elderly, so that they still
maintained the basic principles of the cultured norm
of the Portuguese language and that understanding
was potentialized18. For example, in the question "do
you listen to the problems of others when asked?",
many elderly persons understood "listen to the
problems of others" as something negative, so the
solution found was to rephrase the question "do you
help other people when asked?”.
The phrase "in case of" was used to refine some
questions, in order to reduce the possibility of "not
applicable" answers. For example, the question "do
you have someone to help when you have financial
difficulties?" includes the possibility that some people
have never had financial difficulties. The phrase
was therefore rephrased as "do you have someone
to help you in case of financial difficulty?" A similar
situation occurred in the sentence that was rephrased
as "do you have someone to help you leave the house
in case you need it?”
At times, relatively simple terms created confusion
for the respondents. For example, many elderly
persons confused "have visitors" (receber visitas in
Portuguese) with "pay visits to" (realizar visitas in
Portuguese), so the term was restructured to "do
you often visit?". The term "enduring" was unusual
for this audience and was changed to "permanent".
The same occurred with the term "comfort", which
was modified to "console”.
In general, the construct of Informal Social
Support was familiar and easy to understand for
the elderly persons interviewed, mainly because the
questions were common and had few technical or
scientific terms. However, some reactions of surprise
or delays in responding or negative responses of
understanding or difficulty in repeating the question
that had just been read were noted, as well as
suggestions of alterations by the interviewees, guided
the reformulation of questions which frequently
presented problems.
Limitations of the study included the fact that
the answers of the experts were entirely collected
in online format, which made it difficult for the
responding professionals to explain their concerns
about the items, which may favor the emergence
of response bias in some cases. In addition, the
respondents were not asked for their locality. The
sample used in the face-to-face interviews with the
target audience was from only one city. Ideally, this
should be taken from different cities and regions of
Brazil, in order to include the desired cultural variety
among the interviewees. It is worth highlighting
the importance of other validation steps for this
instrument, such as Factor Analysis, accuracy and
reproducibility analysis, among others, which will
be considered in later sections to reduce the length
of each article and ensure that each stage receives
the proper attention.
CONCLUSIONS
The content-based validity stage identified the
effective relevance of the proposed items through
positive indicators of both the overall and item content

validity index. The suggestions of the specialists led
to the inclusion of two items and the improvement of
the other initially proposed questions. The response
process validity allowed an approximation of the
language used in the instrument to that employed
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Received: June 24, 2018

Reviewed: September 21, 2018
Accepted: September 28, 2018